Local Recurrence

The traditional belief that a 2 cm margin was required for adequate oncological control has been challenged in recent studies.2-4 Conservative techniques, involving excision margins of only a few millimetres, appear to offer excellent oncological control. For example, in a series of 51 patients with 102 surgical margins (skin and deep), 48% measured within 10 mm of the tumor edge and 90% within <20 mm resection margin. Only two patients developed local tumor recurrence during a median follow-up of 26 months which were successfully salvaged with partial penectomy.4 This study and others have encouraged the development of penile-preserving therapies assuming such techniques give the least burden for the patient. If recurrence does occur, the majority can be successfully salvaged without jeopardizing long-term survival^-5 A microscopically incompletely resected primary tumor using penile-preserving surgery is an independent prognosticator for local tumor recurrence.5 Therefore, re-excision is indicated if histopathological analysis reveals tumor-positive surgical margins.

The reader is cautioned that different time-intervals to recurrence have been described for different treatment managements. In patients undergoing brachyther-apy for tumors confined to the glans, the median time to local recurrence in patients

Table 14.1 Overview of recurrence per year and cumulative

Years after primary treatment

Local recurrence (« = 130)

Regional

recurrence (« = 65)

Distant recurrence (n = 10)

Absolute%

Cumulative % (95% CI)

Absolute

% Cumulative % (95% CI)

Absolute %

Cumulative c;

% (95% CI)

Year 1

40.0%

40.0% (31-47.9%)

63.1%

63.1% (49.3-73.1%)

70%

70% (22.7-8:

8.4%)

Year 2

26.2%

66.2% (57-73.4%)

23%

86.1% (74.6-92.4%)

30%

100%

Year 3

10.7%

76.9% (68.4-83.1%)

6.2%

92.3% (82.1-96.7%)

-

-

Year 4

7.7%

84.6% (77-89.7%)

6.2%

98.5% (89.2-99.8%)

-

-

Year 5

3.1%

87.7% (80.5-92.2%)

1.5%

100%

-

-

Adapted from Leijte et al.1

Adapted from Leijte et al.1

was 22 months, with an upper range of even 23 years.6 Twenty percent of the recurrences occurred after 5 years. Thus the primary penile tumor management should be considered when determining the maximal follow-up period.

The local recurrence rate in patients treated with penile-preserving techniques ranges between 20% and 50% in some series,1,5,7-9 and in those who had undergone partial or total penectomy 7%. 1 Consequently, it seems oncologically sound to advise stricter follow-up in those patients undergoing penile-preserving surgery. Although local disease recurrence alone after penile-preserving surgery appears not to have a negative impact on disease-specific survival, every local tumor can be a potential source of new metastatic spread. i 0 Renewed nodal staging and optimal salvage treatment is recommended when patients present with recurrence. Prevention of local recurrence is the best treatment. The selection of the specific surgical techniques depends on tumor stage and localization.11

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